Billing Manual for Community Care Network Providers

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BEHAVIORAL HEALTH MANAGED CARE ORGANIZATIONSPERFORMANCE/OUTCOME MANAGEMENT SYSTEMOUTCOME DIMENSIONS1. Increase Community Tenure and LessRestrictive Services*• Increase the appropriate use of behavioralhealth inpatient days• Decrease criminal incarcerations• Increase the appropriate use of MHresidential care• Decrease out-of-home placements• Decrease homelessness• Decrease placement in C&Y custody• Increase residential stabilityDATA SOURCE(S)1. Quarterly Status File (QSF) 12. Criminal incarceration data sets from statecorrectional3. BH encounter data and SMH data set (PCIS)*To be reported/compiled only for priority groupconsumers by age group (under age 21, 21-64, andage 65+)2. Increase Vocational and Educational Status*• Increase school attendance (full time regularclassroom)• Increase school retention• Increase school performance• Improve school behavior• Increase vocational status for adults1. Quarterly Status File (QSF) 12. Employment tax records*To be reported/compiled only for priority groupconsumers by age group3. Reduce Criminal/Delinquent Activity*• Reduce number of arrests• Reduce positive drug screens• Improve probation/parole status• Reduce status offenses (focus on truancy)*To be reported/compiled only for priority groupconsumers by age group4. Improve Health Care*• Meet or exceed DPW’s EPSDT screening• Increase % of consumers with annualphysical exams• Reduce hospital medical ER use1. Quarterly Status File (QSF) 12. Arrest records (state police)3. Probation and parole records4. Automated Health Systems5. A.O.P.C. records1. Encounter data from physical health HMOs2. Behavioral Health Encounter File (BHEF) 3*To be reported/compiled only for priority groupconsumers by age group5. Increase “Penetration Rates” (i.e., percent ofenrollees who received behavioral healthtreatment through the behavioral health1. Consumer Registry File (CRF) 22. Behavioral Health Encounter File (BHEF) 3Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 214
contractor)• Increase appropriate utilization by prioritygroup and type of service• Increase appropriate utilization by age andtype of service3. Automated Health Systems6. Increase Consumer/Family Satisfaction**To be reported/compiled only for priority groupconsumers by age group1. Consumer Registry File (CRF) 22. Consumer/Family Satisfaction MeasurementInstruments7. Implement Continuous Quality Improvement(CQI) Actions1. CQI Periodic Reports – Behavioral healthcontractor must submit to DPW periodicnarrative reports detailing its CQI activities,delineating deficiencies and areas forimprovement, actions taken to improveperformance (or remedy deficiencies) and theeffectiveness/outcome of actions taken. CQIreports must address performance indicatorreports issued by OMH.8. Increase Range of Services and Improve 1. Behavioral Health Encounter File (BHEF) 3Utilization Patterns• Improve/increase the array of treatment, 2. Encounter data from physical MCOssupport and rehabilitative service options• Decrease % of priority group consumersusing only inpatient and/or ER services• Reduce inpatient rehospitalization rate• Reduce rate of perinatal addictive disorders• Reduce “drop-out” rate•1 Reporting requirements and Data elements for QSF are in the Proposers’ Library2 Reporting requirements and Data elements for CRF are in the Proposers’ Library3 Reporting requirements and Data elements for BHEF are in the Proposers’ LibraryCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 215
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APPENDIX A.2. Confidentiality 130AP
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Clinical Fax by County:Adams 1-866-
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Outpatient Therapy 1MD OutpatientMe
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Functional Familytherapy (FFT)Multi
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Non-Acute PartialHospitalizationNot
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I.A. Code of EthicsCommunity Care
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esources and evaluated on their pro
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Confidentiality policies including
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Within 30 minutes for urban areas.W
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I.E. Care Management Team“Advocat
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In order to serve special populatio
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Psychiatric Rehabilitation Clubhous
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always be considered in light of th
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Tell their provider everything they
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and calls received on the programs
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II.D.1e EvaluationIndividuals parti
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II.D.2b GoalsThe goals of Community
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II.D.3 Providers’ Role in the Pre
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Community Care has a total of 30 ca
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Department of Health and provide in
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An explanation of the grievance pro
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Upon request, the member will be as
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Notices must be in alternate format
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Community Care is a party to the he
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The following sections provide info
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members, practitioners are asked to
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Accreditation of Healthcare Organiz
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III.B.4 Facility ReassessmentFacili
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present relevant information, and t
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contracting, performance evaluation
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the implementation and application
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III.C.4 Ability to Give Informed Au
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When such disclosure to health care
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Practitioners are informed of the r
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Medication(s) that have been prescr
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III.E. Clinical Practice Guidelines
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Community Care has developed a plan
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eing served and uses strategies to
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dialogue and intervention may occur
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For any questions about providing s
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If you, as a Community Care provide
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When the precertification is for se
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ORA member expresses a readiness fo
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IV.E.3 Transition of Care to anothe
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Billing ManualCommunity Care Behavi
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Even though an authorization may be
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Timely File requests are to be mail
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Provide an alternative to the use o
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Required Claim FieldsIn the followi
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24C EMG Not required24D Procedure C
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17 Discharge Status Required forINP
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67a-q Diag. Code Required68 Unlabel
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• Explanation of Benefits (EOB) i
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Many of the services covered by Com
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Community Care Behavioral Health Or
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Community Care Procedure Code: The
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C/FST: Consumer/Family Satisfaction
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Medicaid/Medical Assistance identif
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APPENDICESAPPENDIX A.1. Fraud, Wast
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. The provider will also receive a
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APPENDIX A.2. ConfidentialityPOLICY
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A Facility or group practice name,
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Confidential data and information s
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The medical director or his/her des
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The privacy officer will review the
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collection and use of member identi
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Protection of information disclosed
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If a member is granted access to re
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Under some circumstances, it may be
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164.504(e)(ii)(A)).They will take a
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must verify that the member has sig
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esults, billing records, and treatm
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equestor destroy the information, o
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The member has the right to request
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Policy on Release of Information Re
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y the written authorization of the
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If minor consents to treatment or c
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Page 172 and 173: Findings will be reported to senior
Page 174 and 175: information and by signing this sta
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Page 178 and 179: NameAddress (es)Zip CodeDiagnosis (
Page 180 and 181: Community Care has the right to den
Page 182 and 183: Member identifiable information may
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Page 186 and 187: For research purposes.On behavioral
Page 188 and 189: See the policy on Transition of Pri
Page 190 and 191: Community Care does not collect inf
Page 192 and 193: The request must be in writing. Cre
Page 194 and 195: All statements to the media includi
Page 196 and 197: • The name, or title, and the tel
Page 198 and 199: APPENDIX A.4. Significant Member In
Page 200 and 201: Orientation and ongoing provider ed
Page 202 and 203: CONSENT FOR RELEASE OF INFORMATIONM
Page 204 and 205: Authorization for the Release of Dr
Page 206 and 207: ___________________________________
Page 208 and 209: APPENDIX C.1. Priority PopulationsM
Page 210 and 211: Second priority is associated with
Page 212 and 213: 3. Secondary Data - OMHSAS will dev
Page 216 and 217: APPENDIX E.1. Companion Guide for N
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